Management Of Depression In The Preoperative And Postoperative Phases
The existence of depressive symptoms is not per se a contraindication to DBS surgery. However, ongoing severe depression, psychotic symptoms, and suicidal ideation should be considered absolute contraindications as they might worsen and increase suicidal risk, particularly in the first year after surgery . Less evidence is available regarding severe depressive patients who were eventually stabilized by psychotherapy and medication, months or years prior to undergoing DBS: a trend toward a slightly worse motor and mood outcome has been described, but this certainly does not constitute an absolute contraindication to surgery . In any case, most groups and guidelines support the recommendation of a thorough psychiatric assessment before DBS surgery, and of a careful post-operative follow-up. Of note, the post-operative psychiatric assessment should not be limited to the immediate post-operative period, as the occurrence of apathy, for instance, peaks at around 4 months after surgery, often accompanied by depressive symptoms . Particularly after STN-DBS, which allows for a steeper reduction of dopaminergic medication, dopamine withdrawal symptoms should be prevented, when possible favoring the continued treatment with dopamine agonists .
Dbs Therapy Benefits & Risks
- Less medication, more reliefMedtronic DBS Therapy may reduce Parkinsons medication.1 This may reduce medication-related side effects like unintended movements , while simplifying your medication routine, with fewer pills or less frequent doses.
- Better morningsDBS delivers therapy 24 hours a day it doesnt wear off while you sleep. Its already working the moment you wake up.
- Lifestyle improvementsUnlike some other Parkinsons therapies, the DBS system requires no daily cleaning or refilling.
- More good hours of movement controlEach day, DBS provides additional hours of good movement control without unintended movements , compared to medication alone.1
- A better quality of lifeIn combination with medication, DBS Therapy has helped people with Parkinsons enjoy an improved quality of daily life, compared to those taking medication alone.1
- Keep your options openUnlike some surgeries for Parkinsons, DBS is reversible. The system can be turned off or removed, in most cases, and wont limit your future treatment options.
Patients should always discuss the potential risks and benefits of the therapy with a physician. A prescription is required. DBS Therapy requires brain surgery. Risks of brain surgery may include serious complications such as coma, bleeding inside the brain, stroke, seizures and infection. DBS Therapy may cause worsening of some symptoms. See Important Safety Information.
New Protocols Extend Therapeutic Benefits Of Deep Brain Stimulation
- Carnegie Mellon University
- Researchers have found a way to make deep brain stimulation more precise, resulting in therapeutic effects that outlast what is currently available. The work will significantly advance the study of Parkinson’s disease.
Researchers from Carnegie Mellon University have found a way to make deep brain stimulation more precise, resulting in therapeutic effects that outlast what is currently available. The work, led by Aryn Gittis and colleagues in CMU’s Gittis Lab, will significantly advance the study of Parkinson’s disease.
DBS allows researchers and doctors to use thin electrodes implanted in the brain to send electrical signals to the part of the brain that controls movement. It is a proven way to help control unwanted movement in the body, but patients must receive continuous electrical stimulation to get relief from their symptoms. If the stimulator is turned off, the symptoms return immediately.
Gittis, an associate professor of biological sciences in the Mellon College of Science and faculty in theNeuroscience Institute, said that the new research could change that.
“By finding a way to intervene that has long-lasting effects, our hope is to greatly reduce stimulation time, therefore minimizing side effects and prolonging battery life of implants.”
Teresa Spix, the first author of the paper, said that while there are many strong theories, scientists do not yet fully understand why DBS works.
Deep Brain Stimulation Results
DBS is perhaps most famously used in the treatment of Parkinson’s disease. Prominent actor Michael J. Fox helped to bring Parkinson’s to the eyes of the public when he revealed his diagnosis with the disease. Essential tremor and dystonia are two other movement disorders that are also commonly treated with DBS. Essential tremor is characterized by tremors during muscle movements and is actually the most common movement disorder in the United States. Usually medication alone is sufficient to treat essential tremor, but sometimes severe cases require treatment with DBS.
Dystonia is a disorder resulting in unwanted muscle contractions. Notably, the DBS implantation surgery is performed differently in the case of dystonia. Because dystonia patients are unable to suppress the head and neck movements that are part of their symptoms, the patients must be placed under general anesthesia during the electrode implantation surgery. As we’ll later learn, this situation can make proper electrode implantation more challenging for the doctor.
Parkinson’s disease, essential tremor and dystonia are all movement disorders that share symptoms treatable by DBS stimulation to the basal ganglia. DBS can also be used on brain regions outside the basal ganglia to treat other conditions caused by abnormal brain function. The most common use of DBS is actually for the treatment of chronic pain.
Placement Of The Neurostimulator
This procedure takes place under general anesthesia so that the person is asleep. The surgical team inserts the neurostimulator under the outer layers of skin, usually just under the collarbone, but sometimes in the chest or abdomen. The extension wire from the lead is attached to the neurostimulator.
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With This New Hybrid Dbs System Side Effects Were Significantly Reduced While The Therapy Benefit Was Maintained Or Even Improved
Combining old and new technology
Professor Fasano and Professor Lozano recently published their research into how to reduce unwanted side effects for people implanted with DBS who were otherwise doing reasonably well. In the paper, titled Hybrid DBS system to manage stimulation-induced side effects in essential tremor patients, they offered new programming options by simply upgrading to an advanced battery technology while leaving the old implanted leads in the brain untouched. The results showed that with this new hybrid DBS system, side effects were significantly reduced while the therapy benefit was maintained or even improved.
The difficulty was that this old battery technology did not have the capability of changing the pulse width, so to avoid carrying out an operation to replace the entire existing DBS system, we simply changed the pulse generator where the programming takes place and the selection of the pulse width, explains Professor Lozano.
The results showed that these people had much better tremor control without having the side effects, says Professor Fasano. What we have found in this paper is promising and in the future it will be important to conduct larger, controlled studies to research this further.
Although this paper focuses on people with essential tremor, both Professor Lozano and Professor Fasano believe the results can be reproduced when upgrading to advanced battery technology for people with Parkinsons disease.
What Are The Results
Successful DBS is related to 1) appropriate patient selection, 2) appropriate selection of the brain area for stimulation, 3) precise positioning of the electrode during surgery, and 4) experienced programming and medication management.
For Parkinson’s disease, DBS of the subthalamic nucleus improves the symptoms of slowness, tremor, and rigidity in about 70% of patients . Most people are able to reduce their medications and lessen their side effects, including dyskinesias. It has also been shown to be superior in long term management of symptoms than medications .
For essential tremor, DBS of the thalamus may significantly reduce hand tremor in 60 to 90% of patients and may improve head and voice tremor.
DBS of the globus pallidus is most useful in treatment of dyskinesias , dystonias, as well as other tremors. For dystonia, DBS of the GPi may be the only effective treatment for debilitating symptoms. Though recent studies show little difference between GPi-DBS and STN-DBS.
Patients report other benefits of DBS. For example, better sleep, more involvement in physical activity, and improved quality of life.
Recent research in animals suggest that DBS may “protect” or slow the death of dopamine nerve cells . While the scientific data is inconclusive, observation of DBS patients show potential slowing of the disease relative to their pre-DBS condition.
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Deep Brain Stimulation For Parkinsons Disease
Deep brain stimulation is a surgical intervention used to treat movement disorders such as Parkinsons disease when the regimen of existing medications and the various rehabilitation strategies become less effective in managing symptoms. This surgical procedure received approval from the Food and Drug Administration to treat tremor in Parkinsons disease in July 1997 and for advanced motor symptoms of Parkinsons disease in January 2002.
For people with Parkinsons disease, deep brain stimulation surgery may be helpful if the individual is experiencing motor fluctuations including dyskinesias or “off” episodes.
The subthalamic nucleus and the globus pallidus are two locations in the brain that are targeted in the DBS procedure for Parkinsons. Certain symptoms of Parkinsons disease can be reduced when these two areas are turned “off” by the stimulator. These include tremor, rigidity, slowness of movement, difficulty walking, and “freezing,” as well as extra movements or dyskinesia that are medication side effects. The amount of daily “on” time during which the Parkinsons symptoms are better controlled can be increased as well.
The best marker of whether or not people with Parkinsons disease will benefit from DBS is how well they respond to levodopa, an active ingredient in the drug SinemetTM or carbidopa/levodopa. Patients who benefit most from surgery have had a good response to levodopa. For many, this good response becomes less and less as the disease progresses.
Personality Changes After Deep Brain Stimulation In Parkinsons Disease
1Department of Neuropsychiatry and Psychosomatic Medicine, Oslo University Hospital-Rikshospitalet, 0027 Oslo, Norway
2Department of Gerontopsychiatry, Akershus University Hospital, 1478 Lørenskog, Norway
3Institute of Clinical Medicine, University of Oslo, 0316 Oslo, Norway
4Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, 0027 Oslo, Norway
5Department of Neurology, Oslo University Hospital-Rikshospitalet, 0027 Oslo, Norway
6Department of Biostatistics and Epidemiology, Oslo University Hospital-Rikshospitalet, 0450 Oslo, Norway
7Department of Psychology, University of Oslo, 0316 Oslo, Norway
8Centre for Age-Related Medicine, Stavanger University Hospital, 4068 Stavanger, Norway
9Department of Neurobiology, Care Sciences and Society, Karolinska Institute, 17176 Stockholm, Sweden
Self-report questionnaires have been applied to investigate the effects of STN-DBS on impulsivity. When assessed with the Temperament and Character Inventory-Revised , PD patients treated with DBS reported higher impulsivity scores compared to healthy controls . Using the Barratt Impulsiveness Scale , another study found significantly higher impulsivity scores in DBS-treated patients than in PD patients without DBS . Previous studies were either experimental/lab-based studies or investigated personality traits with only one assessment tool. Collateral information about behavioural change has not been reported.
What To Expect After Dbs
Surgery to implant the leads generally entails an overnight stay, while the IPG is usually implanted as same-day surgery. During recovery, your surgeon will talk to you about caring for your wounds, when you can shower, and any activity restrictions. Its usually recommended that any heavy lifting be avoided for a few weeks.
After another two to four weeks, youll return to have your device programmed. This process will continue for several weeks to ensure the stimulation settings are optimal to control your symptoms. During these visits, you will be shown how to turn the device on and off with the handheld device and check the battery level.
Once the programming has been completed, you will have regular follow-up visits to check and adjust the stimulation to maintain the most benefit for your symptoms.
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Moral Competence And Personality
These are the issues with the most confounding ethical impact. While hypomania subsides and depression may respond to treatment, rarely measurements are taken to exclude less obvious changes in behavior and personality. Fundamental changes in personality have been relatively seldom been studied although basic research documents the role of the STN in decision making . Relatives however report reckless and risk seeking behavior that lasts well beyond the postoperative phase. Again, these types of behavioral change may occur gradually in the natural course of the disease or as side effect of drugsbut the sudden and seemingly irreversible alteration of personally after DBS comes as a shock for families. Probably the most profound, albeit at first sight easily overlooked effects are changes in moral competences of the patients. Such changes may result in taking risks for oneself and ignoring the rights of others, exemplified by car accidents or marital conflicts . Seminars for management of such conflicts after DBS are therefore already offered with patients and spouses reporting their experiences.
Will I Have To Limit My Activity Following Deep Brain Stimulation Surgery
- You should not engage in light activities for 2 weeks after surgery. This includes housework and sexual activity.
- You should not engage in heavy activities for 4 to 6 weeks after surgery. This includes jogging, swimming, or any physical education classes. Anything strenuous should be avoided to allow your surgical wound to heal properly. If you have any questions about activities, call your doctor before performing them.
- You should not lift more than 5 lbs. for at least 2 weeks.
- You should not raise your arms above your shoulders or over bend or stretch your neck.
- Depending on the type of work you do, you may return to work within 4 to 6 weeks.
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How Does The Neurosurgeon Know Where To Place The Electrodes In My Brain
Positioning the electrodes in the brain is the most critical step. The electrodes have to be placed in an exact location in the brain to improve symptoms. Computed tomography or magnetic resonance imaging scans are taken before and/or during the procedure to pinpoint the exact areas to target and guide the lead and electrode placement. Many times an electrode may be used to record brain cell activity at the target site to improve lead placement.
Less Medication More Relief
Medtronic DBS therapy may reduce the need for other Parkinsons medications1 and, consequently, medication-related side effects. DBS delivers therapy 24 hours a day and doesnt wear off while sleeping. Its already working when you wake up.
* Signal may not be present or measurable in all patients. Clinical benefits of brain sensing have not been established.
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How Does Dbs Treat Parkinsons
Parkinsons disease causes irregular electrical signals in parts of the brain that control movement. DBS uses electrical stimulation to modulate these control centers deep to the surface of the brain, improving communication between brain cells.
This helps to reduce symptoms such as tremor, slowness, and stiffness. It doesnt have much of an effect on non-motor symptoms or balance issues. Here are some additional tips for improving motor skills with Parkinsons.
DBS is the most commonly performed surgical procedure for symptoms of Parkinsons disease.
DBS isnt a first-line therapy. Its intended for people whose symptoms are still unmanageable even with medication. Learn about other advanced and future treatments for Parkinsons.
You might be a good candidate for DBS if:
- youve had symptoms for at least five years
- your symptoms respond to medication, but the effect doesnt last as long as it used to
- youve tried various doses and combinations of medications
- your symptoms interfere with everyday life
Your doctor is unlikely to recommend DBS if:
- Parkinsons medications havent helped much
- you have memory and thinking problems
- you have anxiety or depression that hasnt stabilized with treatment
- you have dementia
What Are The Risks
No surgery is without risks. General complications of any surgery include bleeding, infection, blood clots, and reactions to anesthesia. Complications related to placement of the DBS lead include seizures, infection, and a 1% chance of bleeding in the brain.
Reasons for which you might need additional surgery include breakage of the extension wire in the neck parts may wear through the skin and removal of the device due to infection or mechanical failure. Additionally, the battery will need to be replaced every 2 to 5 years. Some DBS systems have a rechargeable battery that may last up to 9 years.
DBS may also cause worsening of some symptoms such as speech and balance impairments. In some patients with Parkinson’s, DBS may cause or worsen depression. If you develop any side effects from a stimulation adjustment, you need to return to the office for further programming.
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How Deep Brain Stimulation Works
Exactly how DBS works is not completely understood, but many experts believe it regulates abnormal electrical signaling patterns in the brain. To control normal movement and other functions, brain cells communicate with each other using electrical signals. In Parkinson’s disease, these signals become irregular and uncoordinated, which leads to motor symptoms. DBS may interrupt the irregular signaling patterns so cells can communicate more smoothly and symptoms lessen.
Adjusting A Deep Brain Stimulation Device To Meet A Patients Needs Takes Time
Four to six weeks after the surgery, patients begin meeting with Orcutt and her colleagues to program the deep brain stimulation device. Together, the patient and care team tune the device so that it delivers the right amount of stimulation to minimize symptoms. Orcutt will see patients regularly until they have identified the appropriate DBS settings. During this time, Orcutt also adjusts patients medications.
This process takes time, she said. There is no formula because everyone is unique. It all depends on a patients condition, where the electrodes are in the brain and what they can tolerate.
Typically, patients will establish their optimal stimulation settings in two to three months following surgery, according to Cooper. Sometimes it happens faster, and sometimes it takes longer, Cooper said. In some cases it may take a year to find the correct DBS settings.
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